Medical Social Worker Pediatric Ambulatory Care Navigator - Ka

Title: Medical Social Worker – Pediatric Ambulatory Care Navigator (Full Time, 40 hours per week)

Location: Kalamazoo, MI

• Support ambulatory care management team and primary care practices in care management and behavioral health delivery of services.
• Conduct outreach to hospital and emergency department discharge patients and coordinate services as needed.
• Provide behavioral health screenings, arrange for detailed assessments, and implement interventions based on evidence‑based clinical guidelines.
• Assist with and update patient‑centered care plans, coordinate care across settings, and monitor progress to optimize patients’ health status.
• Collaborate with primary care physicians, specialists, managed care, and other health care team members to ensure delivery of quality, efficient, and cost‑effective services.
• Serve as a liaison between patients/families and the health care system, addressing psychosocial needs and connecting to community resources.
• Perform crisis assessment and provide appropriate intervention when necessary.
• Maintain accurate documentation of outreach, care management, and behavioral health activities in the electronic medical record.
• Participate in continuous process improvement activities within the system.
• Bill appropriate codes based on payer guidelines and leadership direction.

• Master’s degree in Social Work (M.S.W.) with recent medical or mental health experience, or equivalent experience.
• Licensed Social Worker in good standing with the state of Michigan.
• Strong knowledge of chronic conditions, evidence‑based guidelines, wellness, and health risk assessment.
• Demonstrated interpersonal skills to collaborate effectively with practitioners, the interdisciplinary health care team, community agencies, patients, and families.
• Proven ability to work autonomously, prioritize tasks, and manage time and resources efficiently.
• Excellent communication, problem‑solving, critical thinking, and decision‑making skills.
• Proficiency in word processing, spreadsheets, presentation programs, and other relevant software.

• Sign‑On / Retention Bonus:
  Up to $5,000 for external candidates.
• Full‑time position with 40 scheduled weekly hours.
• First‑shift schedule.

• Shift Type:
  Full time – First Shift